Provider Demographics
NPI:1932496833
Name:JOHNSON, REBECCA FLANNAGAN (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:FLANNAGAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 N 20TH ST # 2
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36801-5449
Mailing Address - Country:US
Mailing Address - Phone:334-745-6447
Mailing Address - Fax:334-742-0713
Practice Address - Street 1:121 N 20TH ST # 2
Practice Address - Street 2:
Practice Address - City:OPELIKA
Practice Address - State:AL
Practice Address - Zip Code:36801-5449
Practice Address - Country:US
Practice Address - Phone:334-745-6447
Practice Address - Fax:334-742-0713
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.765363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131090Medicaid
AL131090Medicaid